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  • 1. Traumatic Spinal Cord Injury:Accidental Versus Nonaccidental InjuryPatrick D. Barnes, MD,*,† Michael V. Krasnokutsky, MD,*,† Kenneth L. Monson, PhD,‡ andJanice Ophoven, MD§ A 21-month-old boy with steroid-dependent asthma presented to the emergency room with Glascow Coma Score (GCS) 3 and retinal hemorrhages. He was found to have subdural and subarachnoid hemorrhage on computed tomography plus findings of hypoxic-ischemic encephalopathy (HIE). The caretaker history was thought to be inconsistent with the clinical and imaging features, and the patient was diagnosed with nonaccidental injury (NAI) and “shaken baby syndrome.” The autopsy revealed a cranial impact site and fatal injury to the cervicomedullary junction. Biomechanical analysis provided further objective support that, although NAI could not be ruled out, the injuries could result from an accidental fall as consistently described by the caretaker. Semin Pediatr Neurol 15:178 –184 © 2008 Elsevier Inc. All rights reserved.N onaccidental injury (NAI) or “shaken baby syndrome” (SBS) is a diagnosis that is often considered in infantspresenting with an acute life-threatening event. Emergency Case Report Clinical Coursephysicians, family practitioners, and pediatricians are of- A 21-month-old boy was brought to the emergency roomten the first to evaluate a child in this situation. Pediatric with a GCS of 3. He reportedly fell onto a tiled floor from aneurologists and neuroradiologists are often consulted in standing position on a kitchen chair while eating. The care-such cases. It has been previously accepted that in the taker saw the child standing in the chair and then turnedabsence of a history of significant trauma (ie, motor vehicle away. He heard but did not see the actual fall and then foundaccident or 2-story fall), the “triad” of (1) infant encepha- the child limp on the floor making gasping sounds. He at-lopathy, (2) subdural hemorrhage (SDH) or subarachnoid tempted to clear food chunks from the child’s mouth andhemorrhage (SAH), and (3) retinal hemorrhages (RHs) is then carried the child to a hospital 10 minutes away. On arrival at the ER, the patient was apneic and pulseless, withdiagnostic of NAI/SBS based on a rotational acceleration- fixed and dilated pupils. Cardiopulmonary resuscitationdeceleration trauma mechanism. This empirical formula (CPR) with chest compressions was applied for approxi-has been challenged by evidence-based medical and legal mately 10 minutes to establish a heart rate. During CPR,standards.1-12 copious amounts of milk and mucus were noted in the We present a case of a toddler with a household fall sce- mouth. The child was intubated and placed on a ventilator.nario resulting in “spinal cord injury without radiographic No evidence of traumatic injury was identified on physicalabnormality” (“SCIWORA”) identified at autopsy.13 The case examination. He was then transported to a pediatric intensivewas initially labeled as NAI/SBS. care unit (PICU) at another facility. Laboratory analysis showed a coagulopathy that was treated with fresh frozen plasma. In the PICU, food particles were suctioned from the lungs and nasopharynx. The patient displayed decortication with occasional gasps but soon became completely unre- sponsive. He was never sedated. An intracranial pressureFrom the *Lucile Packard Children’s Hospital, Palo Alto, CA. monitor recorded an initial pressure of 46 mm Hg with sub-†Stanford University Medical Center, Stanford, CA. sequent pressures ranging from 40 to 70. The initial ophthal-‡University of California San Francisco, San Francisco, CA. mologic examination was done in the PICU and revealed§St Louis County Medical Examiner’s Office, Woodbury, MN.Address reprint requests to Patrick D. Barnes, MD, Department of Radiology, bilateral RHs with perimacular folds. Brain death was subse- Lucile Packard Children’s Hospital, 725 Welch Road, Palo Alto, CA quently documented, and vital support was withdrawn. The 94304. E-mail: patient died 44 hours after the fall.178 1071-9091/08/$-see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.spen.2008.10.009
  • 2. Traumatic spinal cord injury 179Imaging EvaluationThe initial computed tomography (CT) scan obtained within2 hours of the fall showed findings of early diffuse cerebraledema, SDH, and SAH, including a prominent left parietalfocus of SAH and a focal right frontal SDH (Fig 1). A muchsmaller SAH/SDH were also present along the convexities,falx (ie, interhemispheric), and tentorium. There was no ev-idence of brain hemorrhage. No scalp or skull abnormalitieswere identified, although 1 observer could not rule out a“healed” skull fracture along the sutures in the parieto-occip-ital region. A CT scan performed 5 hours later showed pro-gression of the cerebral edema and no change in the SAH orSDH (Fig 2). A CT scan of the cervical spine was negative(Fig 3). Magnetic resonance imaging was recommended butnever obtained. A skeletal survey showed anterior wedge-likevertebral body deformities from T5 through T12 and inferiorL2. Some widening of the cranial sutures was present, but nofractures were confirmed on the plain radiographs. The re-mainder of the survey was negative. A postmortem CT scan ofthe entire spine (Fig 4), confirmed the vertebral deformities. Figure 2 A CT scan performed 5 hours after the initial CT scan shows marked progression of cerebral edema with complete loss of gray/Autopsy Findings by the Medical Examiner white matter differentiation, obliteration of sulci, and near complete obliteration of the ventricular system. A SAH is seen within com-Head and Brain pressed sulci in the left parietal lobe.A focus of hemorrhage was present in the left posteriorparietal scalp (ie, impact site). Microscopy showed acutehemorrhage with acute vital reaction within the fibrousconnective tissue of the galea in that region. Brain weight axonal injury (TAI) observed microscopically on beta-was 1,270 g with the spinal cord attached. No skull frac- amyloid precursor protein (B-APP) immunoperoxidaseture was shown. The brain was extremely swollen with stains. There were bilateral, holohemispheric, thin-layergeneralized flattening and ablation of the normal gyral SDHs with no mass effect.pattern. Histologically, a diffuse axonal injury pattern con-sistent with HIE was present. There were no gross trau-matic brain parenchymal injuries (eg, no contusion orshear lesions) or any histological evidence of traumaticFigure 1 A nonenhanced CT image of the brain preformed within 2hours of the fall shows decreased differentiation of gray/white mat- Figure 3 Sagittal reconstructed CT image of the cervical spine showster representing edema. normal alignment and no fractures.
  • 3. 180 Barnes et al Biomechanical Analysis A court-approved, biomechanical evaluation was performed including an investigation of the home setting where the injury reportedly occurred. A number of potential accidental and NAI (including SBS) scenarios were considered and an- alyzed primarily to address the thoracic spinal injuries and secondarily to address the cervical cord injury. The approach to the biomechanical analysis was to assume that the care- taker’s history was truthful and accurate and to then apply the principle of mechanics to evaluate whether or not such a history could be consistent with the subsequent injuries. This approach was not intended to rule out other possibilities but simply to evaluate the history provided. In that light, the caretaker consistently reported to all au- thorities that he had his back turned at the time of the inci- dent but that the boy had been standing up on the seat of the chair. He then reported hearing a noise and turning to find the boy and the chair on the floor, with the chair lying on its back. Using the caretaker’s consistent history as one scenario,Figure 4 Sagittal reformation of the thoracic spine from a postmor- along with the imaging and clinical findings, the child wastem CT scan shows multilevel anterior wedge compression fractures assumed to have fallen, rotating with the chair until a point ofof varying degrees. separation (Fig 6). From that point, it was further assumed that he fell freely to strike the floor first with his head and then with his dorsal neck and a shoulder, again based on theNeck and Spinal Cord imaging and autopsy findings. This “impact” scenario wouldFocal soft-tissue hemorrhages were present in relation to theright posterior neck and shoulder regions as well as the pos-terolateral transverse processes of the atlas and axis and at theC1-C2 intervertebral junction. No vertebral artery abnormal-ity was noted. The dura appeared tense and filled with blood-stained fluid. Sagittal sections at the cervicomedullary junc-tion showed partial transection and disruption of the centralcord immediately distal to the inferior medullary olives. Thetissue appeared elongated and physically separated suggest-ing axial tension of the cord (Fig 5). The cellular responseconsisted of round and polymorphonuclear cells with acute,focal hemorrhage. Findings of ischemic neuronal degenera-tion were most prominent in, and adjacent to, the dorsal andventral neurons and consisted of cytoplasmic swelling, de-granulization, loss of fine detail, and nuclear pynknosis.EyesOn gross examination, the pigmented layer of the retina wasfocally separated from the choroid. RHs were present primar-ily in the ganglion cell layer anteriorly but extended posteri-orly. An optic nerve sheath hemorrhage was also presentbilaterally. There was no mention of perimacular folds.Vertebral ColumnThe vertebral bodies from T2 through L3 to 4 were removeden bloc. A hemorrhage was seen in the anterior and lateralperivertebral fibroconnective tissues. Microscopic sectionsshowed acute hemorrhage with fibrin deposition replacingnormal marrow of all vertebral bodies. Multiple areas of dis-rupted cancellous bone with acute-phase osteogenic granu- Figure 5 A histological specimen through the cervicomedullarylation tissue were especially prominent T7 through T10. No junction shows complete disruption of the central cord elementscallus or osteoblast activity was present. (circle). (Color version of figure is available online.)
  • 4. Traumatic spinal cord injury 181 34 in), his mass (15.9 kg, 35 lb), and the position of his CG being at approximately 57% his height,7 were used to deter- mine the CG of the combined system (Appendix 1). Thus, the first phase of the fall was modeled with the child and chair combined as an inverted pendulum until the chair reached its natural tipping angle. Vertical and rotational velocities at this point were then used for the initial conditions of the subse- quent free fall, resulting in a predicted impact velocity rang- ing from 3.7 to 4.0 month(s). Impulse momentum was then applied to determine the severity of a fully plastic impact, modeling the child as a single spring-mass system, with the flexing spine serving as the spring, and the mass defined as the measured mass of the child minus that of his head. Be- cause there are limited data available to define an appropriate impact duration, a broad range of 50 to 100 milliseconds wasFigure 6 A schematic representation of the fall. (Color version of considered. Thus, the peak impact force was estimated tofigure is available online.) range between 0.9 and 1.9 N. A free-body diagram of the flexed body was used to determine associated peak thoracic vertebral body forces ranging from 1.4 to 3.1 kiloNewtonsproduce flexion and axial compression with the center of (kN). Forces in the separately considered head impact weremass of his body trailing above. The initial motion of the estimated to be between 3.4 and 3.7 kNs.child was assumed to have produced an initial rotation of thechild and chair together as an inverted pendulum systemabout an axis at the base of the chair’s rear legs. Once the Discussionchair reached its natural tipping angle, however, it was as-sumed to continue in its inverted pendulum motion while NAI/SBSthe child then fell freely to the floor. In this case, the initial “diagnosis” of NAI/SBS was based on Multiple anterior compression fractures of the thoracic the heretofore classic “triad” of SDH, RH, and encephalopa-spine, as reported in this case, are uncommon. The mecha- thy, along with a history presumed to be inconsistent withnism most consistent with this type of injury, however, the injuries. Central nervous system findings that mimic NAI/would be severe flexion and/or axial compression of the SBS have been reported in accidental trauma and in a numberspine. It is problematic, biomechanically, to conclude that of medical conditions.14-21 The latter includes infection, co-such an injury can result from “SBS,” particularly in a child of agulopathy, metabolic disorders, and others.19-21 More recentthis age and size. Further evidence of head and shoulder reports also show that there is no specific pattern of intracra-impact suggests that the necessary loading of the spine may nial hemorrhage that is diagnostic of NAI/SBS to includehave been produced by forces applied to the head, neck, interhemispheric SDH and mixed-density SDH.14-17 Further-and/or shoulder. Thus, we chose to evaluate a scenario in more, recent evidence-based medical reviews (and legal chal-which the boy somehow caused the chair to tip. He then lenges) of the past NAI/SBS literature reveal that the vastrotated with the chair and ultimately fell in such a way that majority of these publications failed to achieve quality ofhis head struck the floor first and quickly rotated to produce evidence ratings that would merit the use of the “triad” as aflexion in the neck and bring the shoulder/lower neck region standard or guideline for proof of NAI/SBS.1-8into contact with the floor. The force acting through the This case also shows the complexities involved in estab-shoulder area then acted to bring the remainder of the child’s lishing the sequence of injuries given multiple findings. Al-body mass to rest, resulting in flexion and axial compression though initial concern for NAI is important and must beof the middle and lower spine. There are clearly many vari- reported, medical personnel must carefully correlate suchables associated with the chosen scenario, including the in- findings with the history to establish a correct sequence offluence of body rotation and whether the child was rotating events, including predisposing factors.19-21 The initiation offorward or backward, but there is no reason to believe the fall the criminal process before a complete and thorough childcould not have occurred as described. Given the selected protection and medical evaluation can lead to a rush in judg-scenario, the next step was to evaluate whether or not the ment. The injuries in this particular case were attributed toforces associated with the respective impacts to the head and SBS before the brain and spinal cord injuries were completelyshoulder/lower neck could have been severe enough to pro- evaluated.22 The father of the victim was charged with fatallyduce the injuries. shaking the child. After all the forensic evidence was consid- Analysis of the chair provided a seat height of 43 cm (17 in) ered, the ultimate verdict was acquittal.and a rearward tipping angle of 23°. The mass of the chair Given the fact that the law requires physicians to reportand its center of gravity (CG) were taken as equal to 6.8 kg suspected NAI, there is the danger of assuming NAI in all(15 lb) and the height of the seat, respectively. The chair cases of SDH and RH. As a result, further medical and imag-measurements, coupled with the height of the child (86 cm, ing workup may not be pursued (eg, magnetic resonance
  • 5. 182 Barnes et alimaging of the brain and cervical spine). The American Acad- Impact Injuryemy of Pediatrics, as others, strongly endorse the use of mag- Although there are no data available defining skull fracturenetic resonance imaging in cases of suspected NAI.17,20,21,23 In thresholds (as an indicator of impact) for a 21-month-old,the absence of an apparent cause of diffuse cerebral edema data reported for younger infants33-36 and adults37 suggest(including HIE), cervical cord injury should be considered. that the calculated head-impact forces are enough to result inAfter the initial CT scan, magnetic resonance imaging is the fracture in at least some of the population. The absence ofchoice for delineating spinal, paraspinal, and intraspinal in- evidence of “significant” trauma to the scalp and skull mayjury. A short tau inversion recovery (STIR) sequence should additionally be explained by the wide distribution of thealways be included because this technique provides the best force along the head, neck, and shoulders at the time ofsensitivity for these types of injury.21 impact. In young children with impact injury, there may be no focal scalp injury or skull fracture on physical examina-SCIWORA tion or by imaging. Therefore, the lack of such findings should not be interpreted as absence of impact injury. Addi-SCIWORA is not uncommon in toddlers and has been re- tionally, fatal and otherwise significant intracranial injuriesported to occur after minor accidental trauma as well as in have been reported from accidental household or short fallscases of alleged NAI.13,24-29 Evidence of a spinal cord injury resulting in the triad of SDH, RH, and encephalopathy.38,39plus cranial, neck, and shoulder impact on the postmortem The biomechanical literature suggests different thresholds forexamination are the key findings in this case. The gross and central nervous system injuries given various scenarios.40-43histological findings, as well as the imaging findings, are en- Neck and cervical spine tissues may have a lower thresholdtirely consistent with the caretaker history of a household fall than brain for minimum forces required to produce trau-as corroborated by the biomechanical evaluation. This is true matic injuries.40for both the primary injury (ie, cord transection) and thesecondary injury (ie, HIE) as reflected in the clinical course ofthe child. SDH and SAH The bony structures of the cervical spine in infants and There are a number of potential causes for the SDH/SAH inyounger children are not fully developed as compared with this case. These include impact trauma, coagulopathy, in-that of the adult. Such “immaturity” includes the horizontal creased ICP, ischemic endothelial damage, and reperfusion.nature of facet joints with flat morphology of uncinate pro- The focal left parietal SAH (Fig 1) correlates with the primarycesses, elastic paraspinal ligaments, and anterior wedge-like site of impact (ie, coupe injury), and the focal left frontal SDHmorphology of the vertebral bodies.13 These factors account may be consistent with contracoupe injury. Further hemor-for the relative ease of vertebral subluxation with complete rhage may be related to the coagulopathy as supported byrecovery of the bony elements to normal anatomical align- laboratory findings. This is a known phenomenon that mayment. This predisposes the child to cervical cord injury in the be initiated by tissue injury caused by trauma or hypoxiaabsence of bony abnormalities. Instantaneous damage to the ischemia.44,45 Once the capillary beds are open and leaking,respiratory centers at the cervicomedullary junction corre- further increases in ICP from brain edema and CPR maylated with the child’s respiratory distress, and subsequent exacerbate this process. Geddes et al32 suggest that additionalHIE lead to extensive edema and increased intracranial pres- factors such as venous and arterial hypertension (HTN) maysure (ICP). exacerbate hemorrhage in the ischemic, swollen brain with increased ICP. They propose both increased oozing from hypoxic veins in the setting of venous HTN secondary toHypoxic-Ischemic severe edema and increased hemorrhage from episodic orVersus Traumatic Axonal Injury sustained arterial HTN (eg, with reperfusion) that may occurGross and microscopic examination showed the effects of as a part of Cushing’s triad or be neurogenic in origin. Addi-severe HIE. There was no evidence of “primary” traumatic tionally, choking, vomiting, or paroxysmal coughing (eg,axonal injury (ie, TAI or shear injury) as an indicator of pertussis) may also result in SDH and RH.46-48 Furthermore,rotational acceleration-deceleration trauma to the brain. The the distribution of SDH or SAH along the interhemisphericprimary injury (ie, TAI) was shown to occur only at the fissure is not pathognomonic for NAI, as previously reported,cervicomedullary junction. In cases of TAI (formerly “diffuse and has been shown to occur in cases of accidental traumaaxonal injury”), distinctive discrete swellings of the the ax- and HIE.14,16,17,21ons, known as axon bulbs, are observed microscopically onB-APP immunoperoxidase stains. These are focal or multifo- RHcal lesions and most often occur along deep gray/white mat- The initial funduscopic documentation of RH was not madeter junctions, the corpus callosum, and dorsal corticospinal until the child was in the PICU. Given the course of events totracts. They may also be associated with focal hemorrhage. that point, the RH may be a result of multiple factors asHIE, whether primary or secondary, results in a diffuse pat- described earlier regarding SDH and SAH. RH is a knowntern of axonal alteration. Furthermore, the histological ap- manifestation of increased ICP. There is no single type orpearance is different from that of TAI, forming a linear or pattern of RH that is pathognomonic of NAI/SBS, and RH isstreak pattern on B-APP staining.30-32 reported in a number of other conditions.15,16,49-57
  • 6. Traumatic spinal cord injury 183Thoracic Spinal InjuryThe multiple thoracic compression fractures in this case areunusual in NAI (SBS) and require biomechanical assessment aswell as consideration of patient risk factors. Based on studies ofcompression fracture in intact cadavers subjected to flexion andcompression testing of both adult human58,59 and pediatric ba-boon vertebral bodies,60 the biomechanical analysis suggestedthe presence of sufficient force to cause the thoracic fractures, inaddition to the cervical spinal cord injury in this case. Additionally, the patient had steroid-dependent asthmatreated with daily beclomethasone dipropionate inhaler for aperiod of 8 months before the fall. During multiple visits tothe emergency room for exacerbations before the reportedfall, he also received additional doses of steroids in a form ofprednisone. Two weeks before the fall, he received 20 mg ofprednisone daily for 6 days. The influence of steroids in thiscase is uncertain. However, such high daily doses of oralsteroids have been shown to significantly increase the risk offractures.61-63 Van Staa et al61 also showed that high dailydoses independent of duration of treatment or prior exposureput the patients at high risk for fractures. The patient also Figure A1 (See appendix). (Color version of figure is available on-presented to the emergency room 3 months before the cur- line.)rent incident after a fall down the stairs. He was evaluatedclinically and released. No imaging was performed at thattime. The postmortem histological examination of the verte-bral column showed evidence of acute trauma. Additionally, is the subsequent free-fall distance of the body CG to thean unusual distribution of diffuse microfractures was ob- floor.served in all bones examined, supporting the possible effect ● Using impulse momentum and assuming a triangularof chronic steroid therapy on bone fragility. It was impossible force pulse and plastic impact, peak force at impactto assess for bone density of the spine during necropsy be- F 2mv , where m is the mass of the object, v iscause the bones were decalcified. impact velocity, and is the duration of impact. ● Compression force on lumbar vertebrae, Fv, is deter- mined by satisfying M I about the ligament attach-Conclusion ment point, as shown in the free-body diagram. Mo-Physicians have an obligation to completely and timely eval- ment-arm distances were scaled from values used byuate suspected NAI, including its mimics. The imaging find- Myklebust et al.58ings alone cannot distinguish NAI from AI or from the med-ical mimics. A complete and thorough medical evaluation, Referencesusing evidence-based medicine principles, is necessary in 1. Donohoe M: Evidence-based medicine and shaken baby syndrome partparallel with the child-protection assessment. A multidisci- I: Literature review, 1966-1998. Am J Forensic Med Pathol 24:239-plinary approach to this evaluation is also important, includ- 242, 2003ing the involvement of qualified specialists. Such an ap- 2. Leestma J: Case analysis of brain injured admittedly shaken infants, 54proach may be the difference between appropriate child cases 1969-2001. Am J Forensic Med Pathol 26:199-212, 2005 3. Lyons: Shaken Baby Syndrome: A Questionable Scientific Syndromeprotection versus the improper breakup of a family or a and a Dangerous Legal Concept. Utah Law Rev 1109, 2003wrongful indictment and conviction. 4. Gena M” Shaken baby syndrome: Medical uncertaintly casts doubt on convictions. Wisc Law Rev 701, 2007 5. Le Fanu J: Wrongful diagnosis of child abuse—A master theory. J R SocAppendix Med 98:249-254, 2006 6. Mackey M: After the Court of Appeal: R v Harris and others [2005]Equations Used in Biomechanical Analysis EWCA crim 1980. Arch Dis Child 91:873-875, 2006 ● Angular velocity of combined chair-child system at end 7. Richards P, Bertocci G, Bonshek R, et al: Shaken baby syndrome. Before of inverted pendulum phase was determined as the court of appeal. Arch Dis Child 91:205-206, 2006 8. Baath J: Shaken baby syndrome: The debate rages on U. Toronto Med J 2 g L 1 cos , where L is height of combined 83:22-23, 2005 system center of mass and is angle of rotation from 9. Squier W: Shaken baby syndrome: The quest for evidence. Develop vertical position (Fig A1). Med Child Neurol 50:10-14, 2008 ● From conservation of energy, impact velocity v 10. Gilliland MGF: Use of the triad of scant SDH, brain swelling, and retinal hemorrhages to diagnose non-accidental injury is not scientifically v2 2gH where vz is the vertical component of linear z valid. National Association of Medical Examiners National Meeting, velocity at the end of the inverted pendulum phase and H October 2006 (abstr 53)
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